This is the longest period I have ever gone without writing a post.  The long pause was necessary because of changes in personal goals and the world at large.   EHR Science has covered a range of topics over the years—everything from EHR market trends to discrete mathematics.   Topics discussed reflected both current events and my curiosity.  A little more than four years later, curiosity has given way to abiding interest, and abiding interest to new goals and challenges. Readers’ interests have changed as well.  Early on, selection and implementation were the big topics, then MU (which nows appears to be officially dead), and now many are into optimizing installed systems.  Things are different; I am different — time to reassess.

As it happens, I have very little interest in optimizing data-centric systems; that is the job of vendors’ R & D departments.  My interest lies in the science of clinical systems—uncovering engineering principles, creating mathematical models, and representing clinical processes computationally. These are my passions, and I have decided to pursue them wholeheartedly. 

Practically, this means that my business projects and my passions will reflect one another completely. 

With MU on its way out, and the apparent shift in focus to APIs and interoperability, innovation in clinical care systems can move forward, and I want to be knee-deep in and hands-on with the next generation of clinical systems. However, my vision is likely not the same as most who talk about HIT innovation.   The metaphor of the chart as the basis for clinical care systems is well past its time.   I am not saying that those systems cannot be tweaked further, only that their basic designs limit how much they can change.   Process-aware technology is the future for decision support, preventive care, care coordination, results management, and other major aspects of clinical care.  Yes, it is possible to emulate some aspects of process-awareness in data-centric systems, but the work required to do so is disproportionate to the benefit.  Process-aware systems also have a formal mathematical basis.  Yawn…right? ; for the moment, perhaps… But when trying to do science or engineering, math always helps—a lot. For my part, I’m going all-in on processes and math.

The hoped-for advances in technology are finally here.  The first generation of mobile devices with sufficient capability to support next-generation clinical care systems is finally here in the guise of the iPad Pro. This is a BIG deal.   It is the 2015 equivalent of the IBM PC AT, and will have the same effects. 

Tablets are better than browsers for supporting complex applications, and the Internet plus APIs make tablets more flexible and capable for delivering sophisticated applications.  The range of inputs available—voice, gestures, motion, keyboard—means that applications that use these capabilities have to be imagined from the ground up. They cannot be clunky ports of web-based or client/server applications from the 2000s or earlier.

In order to judge the value of a platform, applications must be written for that platform with its strengths in mind.  Too much clinical software went from client/server to web to mobile without being properly reimagined for each platform. Simply substituting gestures for mouse clicks never turns out well.  The result has been bad user interfaces, too many clicks, poor process support, and scribes. MU made things even worse.  UCD can help somewhat. Even so, users are very good at describing what they do not like; they are rarely the source of visionary breakthroughs.  Mainframe users did not give us PCs. Cellphone focus groups did not imagine the iPhone.  Radio lovers did not suggest television.  Data-centric software vendors will not likely be the first to produce process-aware systems.  It’s not impossible, but history suggests otherwise.

Digital glue in the form of APIs is maturing rapidly!  APIs provide a reliable means of accessing new capabilities or data and make software development much easier.  These days it seems everything has an API and every data store has ReST capability. Digital glue will allow small developers to build more complex products more quickly.  Another possible outcome is the development of small companies that build clinical care system components for others to use in their software. 

What is in store for EHR Science?  Well, not much directly.  EHR Science will become one of a family of sites.  I am setting up separate sites because EHR Science readers have changed significantly over the last two years.  Initially, most EHR Science readers were informaticists. Now, significantly more are software developers, UX professionals,  and BPM professionals.  Software developers might find posts on information models or design patterns interesting, the other groups not so much.  Likewise, when I start discussing capturing clinical work patterns in YAWL, few software developers would have any idea what I am talking about.  Accordingly, Clinical Swift will get its own website.  It will be home to clinical software engineering posts, app development tutorials,  and detailed discussions of clinical software design.    

Clinical Workflow Center (CWC) will continue as-is except that more articles discussing clinical processes and workflow patterns will appear.   Next up for CWC, a tutorial series: BPMN for Clinical Systems. 

Business-wise,  my consulting efforts will focus on mobile and process-aware systems/services.  For the next six-eight months, my time will be divided between two application development demo projects.  The On-Call Assistant for Clinical Swift that has appeared on EHR Science will move to the new Clinical Swift site.   The process demonstration project, which is yet unnamed, will look at results management using Bonitasoft and BPMN.  A new business site for Informatics Squared, Inc., sans EHR consulting services, will debut shortly.

EHR Science, Clinical Swift, and Clinical Workflow Center will have weekly posts (at least) and all will be linked so readers can easily follow their interests.   No more fence-sitting, or Hamlet-esque waffling—I’m going all-in on the next-generation of clinical care systems!

Look for the new Clinical Swift site and regular posts on all three to restart in four weeks. 

Happy New Year!!!



  1. Hi Dr. Carter,

    I’ve been a reader for several years. I’ve learned a lot from you, as I am a physician with zero IT background. I do have experience and strong interest in process improvement in general, separate from EMRs and the role of technology in healthcare.

    As a rule, workflows in healthcare are pretty inefficient and wasteful. This has always been true, well before EMRs and MU arrived.

    I would be interested to hear your thoughts on how workflow analysis tools can be used to improve healthcare workflows, perhaps incorporated with Lean methods, for instance.


    1. Author

      Hi Mark, thanks for your comment!

      Workflow analysis is a means of finding out how processes occur and why. In addition, workflows result in outcomes, so making any process better requires understanding its intended outcome and the steps that produce that outcome. In healthcare, these ideas are not usually considered as a group. Moreover, most WF analyses have been done with software implementation in mind, not understanding clinical care processes.

      WF advocacy is not a plea for efficiency, although in some cases that might be desirable (e.g., better matching of potential patients to open appointments), but more so for understanding exactly how a clinical care produces outcomes. WF info can be used to design software, new services, or improve basic clinical practice (e.g., care coordination or results management).

      Lean is a management philosophy that can be used to improve systems by removing encumbrances and focusing on outcomes. At its best, Lean avoids rigid thinking and encourages experimentation. WF analysis is the perfect tool for capturing system behavior, especially in formal approaches are used such as WF patterns, graph theory, BPMN, YAWL, etc. WF analysis is a solid complement to any improvement approach.

  2. This is really exciting- I have found your site and writing to always be a few steps ahead of my concerns and extremely well thought out and presented. Now there will be even more! I look forward to everything!!!

    1. Author

      Thanks Pat! We live in exciting times, on the brink of huge changes in HIT. It may not seem obvious, but everything is in place. Technology changes since 2007 have been significant and few have made their way to HIT–NoSQL, mobile, ReST, better web development tools, broader embrace of design patterns/OOP/APIs, workflow tech with formal underpinning, and hi-speed networks. Yet major HIT systems (EHRs) are classic 1990s client/server, data-centric designs. Change is inevitable…

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